1
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Li X, Wang Y, Xia B, Che H, Yan Z. Lumboperitoneal shunt and ventriculoperitoneal shunt for chronic hydrocephalus after aneurysmal subarachnoid hemorrhage: a comparison. Front Surg 2024; 11:1368493. [PMID: 38533091 PMCID: PMC10963422 DOI: 10.3389/fsurg.2024.1368493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Accepted: 03/04/2024] [Indexed: 03/28/2024] Open
Abstract
Objective Chronic hydrocephalus after aneurysmal subarachnoid hemorrhage (aSAH) results in poor neurological outcomes and cognitive deficits. Currently, the main treatments for chronic hydrocephalus include ventriculoperitoneal shunt (VPS) and lumboperitoneal shunt (LPS); however, the optimal treatment for chronic hydrocephalus after aSAH remains controversial. Method The records of 82 patients were retrospectively analyzed, and the patients were divided into VPS and LPS groups based on surgical methods. The efficacy, shunt successful rate and complications were compared. The assessments of treatment efficacy included the Evans index score (EIS), Keifer's hydrocephalus score (KHS), Mini-Mental State Examination (MMSE) score and functional independence measure (FIM). Patients were followed up for three months to observe the postoperative curative effects and complications. Results The rate of shunt obstruction was significantly higher in the LPS group than that in the VPS group (p < 0.05), and the shunt successful rate was significantly higher in the VPS group than that in the LPS group (p < 0.05). The total rate of complications was 24.4% for LPS and 39% for VPS. The improvements in EIS, KHS, MMSE, and FIM within each group after the shunt were significantly different compared to those before shunt (p < 0.05). Compared to those in the LPS group, the improvements in EIS, KHS, MMSE, and FIM were significantly different in the VPS group after shunt (p < 0.05). Conclusion Compared with LPS, VPS in the treatment for chronic hydrocephalus after aSAH had greater therapeutic efficacy, as indicated by improved radiological outcomes, improved shunt successful rate, improved clinical outcomes, and improved quality of life. Therefore, we believe that VPS is the preferred treatment option for chronic hydrocephalus after aSAH, while LPS should only be used as an alternative to VPS.
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Affiliation(s)
| | | | | | | | - Zhongnan Yan
- Department of Neurosurgery, Xi’an Gaoxin Hospital, Xi’an, Shaanxi, China
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2
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Ramasy Razafindratovo RM, Chevret S, Champeaux-Depond C. Failure of Internal Cerebrospinal Fluid Shunt: A Systematic Review and Meta-Analysis of the Overall Prevalence in Adults. World Neurosurg 2023; 169:20-30. [PMID: 36309337 DOI: 10.1016/j.wneu.2022.10.073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 10/19/2022] [Indexed: 11/07/2022]
Abstract
OBJECTIVE Reported rates of failures of internal cerebrospinal fluid shunt (ICSFS) vary greatly from less than 5% to more than 50% and no meta-analysis to assess the overall prevalence has been performed. We estimated the failure rate after ICSFS insertion and searched for associated factors. METHODS Six databases were searched from January 1990 to February 2022. Only original articles reporting the rate of adult shunt failure were included. Random-effects meta-analysis with a generalized linear mixed model method and logit transformation was used to compute the overall failure prevalence. Subgroup analysis and meta-regression were implemented to search for associated factors. RESULTS Of 1763 identified articles, 46 were selected, comprising 70,859 ICSFS implantations and 13,603 shunt failures, suggesting an accumulated incidence of 19.2%. However, the calculated pooled prevalence value and its 95% confidence interval (CI) were 22.7% (95% CI, 19.8-5.8). The CI of the different estimates did not overlap, indicating a strong heterogeneity confirmed by a high I2 of 97.5% (95% CI, 97.1-97.8; P < 0.001; τ2 = 0.3). Ninety-five percent prediction interval of shunt failure prevalence ranged from 8.75% to 47.36%. A meta-regression of prevalence of publication found a barely significant decreasing failure rate of about 2% per year (-2.11; 95% CI, -4.02 to -0.2; P = 0.031). CONCLUSIONS Despite being a simple neurosurgical procedure, ICSFS insertion has one of the highest risk of complications, with failure prevalence involving more than 1 patient of 5. Nonetheless, all efforts to lower this high level of shunt failure seem to be effective.
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Affiliation(s)
- Rado Malalatiana Ramasy Razafindratovo
- Service de biostatistique et information médicale, Hôpital Saint-Louis, Paris, France; INSERM U1153, Statistic and Epidemiologic Research Center Sorbonne Paris Cité (CRESS), ECSTRRA Team, Université de Paris, Paris, France
| | - Sylvie Chevret
- Service de biostatistique et information médicale, Hôpital Saint-Louis, Paris, France; INSERM U1153, Statistic and Epidemiologic Research Center Sorbonne Paris Cité (CRESS), ECSTRRA Team, Université de Paris, Paris, France
| | - Charles Champeaux-Depond
- Service de biostatistique et information médicale, Hôpital Saint-Louis, Paris, France; INSERM U1153, Statistic and Epidemiologic Research Center Sorbonne Paris Cité (CRESS), ECSTRRA Team, Université de Paris, Paris, France; Department of Neurosurgery, Larbiboisière Hospital, Paris, France.
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3
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Isaacs AM, Ball CG, Sader N, Muram S, Ben-Israel D, Urbaneja G, Dronyk J, Holubkov R, Hamilton MG. Reducing the risks of proximal and distal shunt failure in adult hydrocephalus: a shunt outcomes quality improvement study. J Neurosurg 2022; 136:877-886. [PMID: 34450584 DOI: 10.3171/2021.2.jns202970] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Accepted: 02/11/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Patient outcomes of ventriculoperitoneal (VP) shunt surgery, the mainstay treatment for hydrocephalus in adults, are poor because of high shunt failure rates. The use of neuronavigation or laparoscopy can reduce the risks of proximal or distal shunt catheter failure, respectively, but has less independent effect on overall shunt failures. No adult studies to date have combined both approaches in the setting of a shunt infection prevention protocol to reduce shunt failure. The goal of this study was to determine whether combining neuronavigation and laparoscopy with a shunt infection prevention strategy would reduce the incidence of shunt failures in adult hydrocephalic patients. METHODS Adult patients (age ≥ 18 years) undergoing VP shunt surgery at a tertiary care institution prior to (pre-Shunt Outcomes [ShOut]) and after (post-ShOut) the start of a prospective continuous quality improvement (QI) study were compared. Pre-ShOut patients had their proximal and distal catheters placed under conventional freehand approaches. Post-ShOut patients had their shunts inserted with neuronavigational and laparoscopy assistance in placing the distal catheter in the perihepatic space (falciform technique). A shunt infection reduction protocol had been instituted 1.5 years prior to the start of the QI initiative. The primary outcome of interest was the incidence of shunt failure (including infection) confirmed by standardized criteria indicating shunt revision surgery. RESULTS There were 244 (115 pre-ShOut and 129 post-ShOut) patients observed over 7 years. With a background of shunt infection prophylaxis, combined neuronavigation and laparoscopy was associated with a reduction in overall shunt failure rates from 37% to 14%, 45% to 22%, and 51% to 29% at 1, 2, and 3 years, respectively (HR 0.44, p < 0.001). Shunt infection rates decreased from 8% in the pre-ShOut group to 0% in the post-ShOut group. There were no proximal catheter failures in the post-ShOut group. The 2-year rates of distal catheter failure were 42% versus 20% in the pre- and post-ShOut groups, respectively (p < 0.001). CONCLUSIONS Introducing a shunt infection prevention protocol, placing the proximal catheter under neuronavigation, and placing the peritoneal catheter in the perihepatic space by using the falciform technique led to decreased rates of infection, distal shunt failure, and overall shunt failure.
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Affiliation(s)
| | - Chad G Ball
- 2Department of Surgery, University of Calgary
| | | | | | | | - Geberth Urbaneja
- 3Adult Hydrocephalus Program, Department of Clinical Neuroscience, University of Calgary, Alberta, Canada; and
| | - Jarred Dronyk
- 3Adult Hydrocephalus Program, Department of Clinical Neuroscience, University of Calgary, Alberta, Canada; and
| | - Richard Holubkov
- 4Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah
| | - Mark G Hamilton
- 1Division of Neurosurgery, University of Calgary.,3Adult Hydrocephalus Program, Department of Clinical Neuroscience, University of Calgary, Alberta, Canada; and
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4
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Deng H, Goldschmidt E, Nwachuku E, Yue JK, Angriman F, Wei Z, Agarwal N, Puccio AM, Okonkwo DO. Hydrocephalus and Cerebrospinal Fluid Analysis Following Severe Traumatic Brain Injury: Evaluation of a Prospective Cohort. Neurol Int 2021; 13:527-534. [PMID: 34698266 PMCID: PMC8544497 DOI: 10.3390/neurolint13040052] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Revised: 10/11/2021] [Accepted: 10/12/2021] [Indexed: 11/17/2022] Open
Abstract
The development of hydrocephalus after severe traumatic brain injury (TBI) is an under-recognized healthcare phenomenon and can increase morbidity. The current study aims to characterize post-traumatic hydrocephalus (PTH) in a large cohort. Patients were prospectively enrolled age 16-80 years old with Glasgow Coma Scale (GCS) score ≤8. Demographics, GCS, Injury Severity Score (ISS), surgery, and cerebrospinal fluid (CSF) were analyzed. Outcomes were shunt failure and Glasgow Outcome Scale (GOS) at 6 and 12-months. Statistical significance was assessed at p < 0.05. In 402 patients, mean age was 38.0 ± 16.7 years and 315 (78.4%) were male. Forty (10.0%) patients developed PTH, with predominant injuries being subdural hemorrhage (36.4%) and diffuse axonal injury (36.4%). Decompressive hemicraniectomy (DHC) was associated with hydrocephalus (OR 3.62, 95% CI (1.62-8.07), p < 0.01). Eighteen (4.5%) patients had shunt failure and proximal obstruction was most common. Differences in baseline CSF cell count were associated with increased shunt failure. PTH was not associated with worse outcomes at 6 (p = 0.55) or 12 (p = 0.47) months. Hydrocephalus is a frequent sequela in 10.0% of patients, particularly after DHC. Shunt placement and revision procedures are common after severe TBI, within the first 4 months of injury and necessitates early recognition by the clinician.
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Affiliation(s)
- Hansen Deng
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA; (E.N.); (Z.W.); (N.A.); (A.M.P.); (D.O.O.)
| | - Ezequiel Goldschmidt
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA 94143, USA;
| | - Enyinna Nwachuku
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA; (E.N.); (Z.W.); (N.A.); (A.M.P.); (D.O.O.)
| | - John K. Yue
- Department of Critical Care Medicine, Sunnybrook Health Sciences Center, University of Toronto, Toronto, ON M4N 3M5, Canada; (J.K.Y.); (F.A.)
| | - Federico Angriman
- Department of Critical Care Medicine, Sunnybrook Health Sciences Center, University of Toronto, Toronto, ON M4N 3M5, Canada; (J.K.Y.); (F.A.)
| | - Zhishuo Wei
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA; (E.N.); (Z.W.); (N.A.); (A.M.P.); (D.O.O.)
| | - Nitin Agarwal
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA; (E.N.); (Z.W.); (N.A.); (A.M.P.); (D.O.O.)
| | - Ava M. Puccio
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA; (E.N.); (Z.W.); (N.A.); (A.M.P.); (D.O.O.)
- Neurotrauma Clinical Trials Center, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
| | - David O. Okonkwo
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA; (E.N.); (Z.W.); (N.A.); (A.M.P.); (D.O.O.)
- Neurotrauma Clinical Trials Center, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
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5
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Hosainey SAM, Hald JK, Meling TR. Risk of early failure of VP shunts implanted for hydrocephalus after craniotomies for brain tumors in adults. Neurosurg Rev 2021; 45:479-490. [PMID: 33905002 PMCID: PMC8827213 DOI: 10.1007/s10143-021-01549-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 03/28/2021] [Accepted: 04/12/2021] [Indexed: 11/25/2022]
Abstract
Risks and survival times of ventriculoperitoneal (VP) shunts implanted due to hydrocephalus after craniotomies for brain tumors are largely unknown. The purpose of this study was to determine the overall timing of VP shunting and its failure after craniotomy for brain tumors in adults. The authors also wished to explore risk factors for early VP shunt failure (within 90 days). A population-based consecutive patient cohort of all craniotomies for intracranial tumors leading to VP shunt dependency in adults (> 18 years) from 2004 to 2013 was studied. Patients with pre-existing VP shunts prior to craniotomy were excluded. The survival time of VP shunts, i.e., the shunt longevity, was calculated from the day of shunt insertion post-craniotomy for a brain tumor until the day of shunt revision requiring replacement or removal of the shunt system. Out of 4774 craniotomies, 85 patients became VP shunt-dependent (1.8% of craniotomies). Median time from craniotomy to VP shunting was 1.9 months. Patients with hydrocephalus prior to tumor resection (N = 39) had significantly shorter time to shunt insertion than those without (N = 46) (p < 0.001), but there was no significant difference with respect to early shunt failure. Median time from shunt insertion to shunt failure was 20 days (range 1–35). At 90 days, 17 patients (20%) had confirmed shunt failure. Patient age, sex, tumor location, primary/secondary craniotomy, extra-axial/intra-axial tumor, ventricular entry, post-craniotomy bleeding, and infection did not show statistical significance. The risk of early shunt failure (within 90 days) of shunts after craniotomies for brain tumors was 20%. This study can serve as benchmark for future studies.
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Affiliation(s)
| | - John K Hald
- Department of Radiology and Nuclear Medicine, Oslo University Hospital, Oslo, Norway
- Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Torstein R Meling
- Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Neurosurgery, Oslo University Hospital, Oslo, Norway
- Department of Neurosurgery, Geneva University Hospitals, Geneva, Switzerland
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
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6
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Nakajima M, Yamada S, Miyajima M, Ishii K, Kuriyama N, Kazui H, Kanemoto H, Suehiro T, Yoshiyama K, Kameda M, Kajimoto Y, Mase M, Murai H, Kita D, Kimura T, Samejima N, Tokuda T, Kaijima M, Akiba C, Kawamura K, Atsuchi M, Hirata Y, Matsumae M, Sasaki M, Yamashita F, Aoki S, Irie R, Miyake H, Kato T, Mori E, Ishikawa M, Date I, Arai H. Guidelines for Management of Idiopathic Normal Pressure Hydrocephalus (Third Edition): Endorsed by the Japanese Society of Normal Pressure Hydrocephalus. Neurol Med Chir (Tokyo) 2021; 61:63-97. [PMID: 33455998 PMCID: PMC7905302 DOI: 10.2176/nmc.st.2020-0292] [Citation(s) in RCA: 179] [Impact Index Per Article: 59.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
Among the various disorders that manifest with gait disturbance, cognitive impairment, and urinary incontinence in the elderly population, idiopathic normal pressure hydrocephalus (iNPH) is becoming of great importance. The first edition of these guidelines for management of iNPH was published in 2004, and the second edition in 2012, to provide a series of timely, evidence-based recommendations related to iNPH. Since the last edition, clinical awareness of iNPH has risen dramatically, and clinical and basic research efforts on iNPH have increased significantly. This third edition of the guidelines was made to share these ideas with the international community and to promote international research on iNPH. The revision of the guidelines was undertaken by a multidisciplinary expert working group of the Japanese Society of Normal Pressure Hydrocephalus in conjunction with the Japanese Ministry of Health, Labour and Welfare research project. This revision proposes a new classification for NPH. The category of iNPH is clearly distinguished from NPH with congenital/developmental and acquired etiologies. Additionally, the essential role of disproportionately enlarged subarachnoid-space hydrocephalus (DESH) in the imaging diagnosis and decision for further management of iNPH is discussed in this edition. We created an algorithm for diagnosis and decision for shunt management. Diagnosis by biomarkers that distinguish prognosis has been also initiated. Therefore, diagnosis and treatment of iNPH have entered a new phase. We hope that this third edition of the guidelines will help patients, their families, and healthcare professionals involved in treating iNPH.
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Affiliation(s)
- Madoka Nakajima
- Department of Neurosurgery, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Shigeki Yamada
- Department of Neurosurgery, Shiga University of Medical Science, Ohtsu, Shiga, Japan
| | - Masakazu Miyajima
- Department of Neurosurgery, Juntendo Tokyo Koto Geriatric Medical Center, Tokyo, Japan
| | - Kazunari Ishii
- Department of Radiology, Kindai University Faculty of Medicine, Osakasayama, Osaka, Japan
| | - Nagato Kuriyama
- Department of Epidemiology for Community Health and Medicine, Kyoto Prefectural University of Medicine, Graduate School of Medical Science, Kyoto, Kyoto, Japan
| | - Hiroaki Kazui
- Department of Neuropsychiatry, Kochi Medical School, Kochi University, Nankoku, Kochi, Japan
| | - Hideki Kanemoto
- Department of Psychiatry, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Takashi Suehiro
- Department of Psychiatry, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Kenji Yoshiyama
- Department of Psychiatry, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Masahiro Kameda
- Department of Neurological Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Okayama, Japan
| | - Yoshinaga Kajimoto
- Department of Neurosurgery, Division of Surgery, Osaka Medical College, Takatsuki, Osaka, Japan
| | - Mitsuhito Mase
- Department of Neurosurgery, Nagoya City University, Graduate School of Medical Sciences, Nagoya, Aichi, Japan
| | - Hisayuki Murai
- Department of Neurosurgery, Chibaken Saiseikai Narashino Hospital, Narashino, Chiba, Japan
| | - Daisuke Kita
- Department of Neurosurgery, Noto General Hospital, Nanao, Ishikawa, Japan
| | - Teruo Kimura
- Department of Neurosurgery, Kitami Red Cross Hospital, Kitami, Hokkaido, Japan
| | - Naoyuki Samejima
- Department of Neurosurgery, Tokyo Kyosai Hospital, Federation of National Public Service Personnel Mutual Aid Associations, Tokyo, Japan
| | - Takahiko Tokuda
- Department of Functional Brain Imaging Research, National Institute of Radiological Science, National Institutes for Quantum and Radiological Science and Technology, Chiba, Chiba, Japan
| | - Mitsunobu Kaijima
- Department of Neurosurgery, Hokushinkai Megumino Hospital, Eniwa, Hokkaido, Japan
| | - Chihiro Akiba
- Department of Neurosurgery, Juntendo Tokyo Koto Geriatric Medical Center, Tokyo, Japan
| | - Kaito Kawamura
- Department of Neurosurgery, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Masamichi Atsuchi
- Normal Pressure Hydrocephalus Center, Jifukai Atsuchi Neurosurgical Hospital, Kagoshima, Kagoshima, Japan
| | - Yoshihumi Hirata
- Department of Neurosurgery, Kumamoto Takumadai Hospital, Kumamoto, Kumamoto, Japan
| | - Mitsunori Matsumae
- Department of Neurosurgery at Tokai University School of Medicine, Isehara, Kanagawa, Japan
| | - Makoto Sasaki
- Division of Ultrahigh Field MRI, Institute for Biomedical Sciences, Iwate Medical University, Yahaba, Iwate, Japan
| | - Fumio Yamashita
- Division of Ultrahigh Field MRI, Institute for Biomedical Sciences, Iwate Medical University, Yahaba, Iwate, Japan
| | - Shigeki Aoki
- Department of Radiology, Juntendo University School of Medicine, Tokyo, Japan
| | - Ryusuke Irie
- Department of Radiology, Juntendo University School of Medicine, Tokyo, Japan
| | - Hiroji Miyake
- Nishinomiya Kyoritsu Rehabilitation Hospital, Nishinomiya, Hyogo, Japan
| | - Takeo Kato
- Division of Neurology and Clinical Neuroscience, Department of Internal Medicine III, Yamagata University School of Medicine, Yamagata, Yamagata, Japan
| | - Etsuro Mori
- Department of Behavioral Neurology and Neuropsychiatry, Osaka University United Graduate School of Child Development, Suita, Osaka, Japan
| | - Masatsune Ishikawa
- Department of Neurosurgery and Normal Pressure Hydrocephalus Center, Rakuwakai Otowa Hospital, Kyoto, Kyoto, Japan
| | - Isao Date
- Department of Neurological Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Okayama, Japan
| | - Hajime Arai
- Department of Neurosurgery, Juntendo University Faculty of Medicine, Tokyo, Japan
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Garegnani L, Franco JV, Ciapponi A, Garrote V, Vietto V, Portillo Medina SA. Ventriculo-peritoneal shunting devices for hydrocephalus. Cochrane Database Syst Rev 2020; 6:CD012726. [PMID: 32542676 PMCID: PMC7388891 DOI: 10.1002/14651858.cd012726.pub2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND Hydrocephalus is a common neurological disorder, caused by a progressive accumulation of cerebrospinal fluid (CSF) within the intracranial space that can lead to increased intracranial pressure, enlargement of the ventricles (ventriculomegaly) and, consequently, to brain damage. Ventriculo-peritoneal shunt systems are the mainstay therapy for this condition, however there are different types of shunt systems. OBJECTIVES To compare the effectiveness and adverse effects of conventional and complex shunt devices for CSF diversion in people with hydrocephalus. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (2020 Issue 2); Ovid MEDLINE (1946 to February 2020); Embase (Elsevier) (1974 to February 2020); Latin American and Caribbean Health Science Information Database (LILACS) (1980 to February 2020); ClinicalTrials.gov; and World Health Organization International Clinical Trials Registry Platform. SELECTION CRITERIA We selected randomised controlled trials or quasi-randomised trials of different types of ventriculo-peritoneal shunting devices for people with hydrocephalus. Primary outcomes included: treatment failure, adverse events and mortality. DATA COLLECTION AND ANALYSIS Two review authors screened studies for selection, assessed risk of bias and extracted data. Due to the scarcity of data, we performed a Synthesis Without Meta-analysis (SWiM) incorporating GRADE for the quality of the evidence. MAIN RESULTS We included six studies with 962 participants assessing the effects of standard valves compared to anti-syphon valves, other types of standard valves, self-adjusting CSF flow-regulating valves and external differential programmable pressure valves. All included studies started in a hospital setting and offered ambulatory follow-up. Most studies were conducted in infants or children with hydrocephalus from diverse causes. The certainty of the evidence for most comparisons was low to very low. 1. Standard valve versus anti-syphon valve Three studies with 296 randomised participants were included under this comparison. We are uncertain about the incidence of treatment failure in participants with standard valve and anti-syphon valves (very low certainty of the evidence). The incidence of adverse events may be similar in those with standard valves (range 0 to 1.9%) and anti-syphon valves (range 0 to 2.9%) (low certainty of the evidence). Mortality may be similar in those with standard valves (0%) and anti-syphon valves (0.9%) (RD 0.01%, 95% CI -0.02% to 0.03%, low certainty of the evidence). Ventricular size and head circumference may be similar in those with standard valves and anti-syphon valves (low certainty of the evidence). None of the included studies reported the quality of life of participants. 2. Comparison between different types of standard valves Two studies with 174 randomised participants were included under this comparison. We are uncertain about the incidence of treatment failure in participants with different types of standard valves (early postoperative period: RR 0.41, 95% CI 0.13 to 1.27; at 12 months follow-up: RR 1.17, 95% CI 0.72 to 1.92, very low certainty of the evidence). None of the included studies reported adverse events beyond those included under "treatment failure". We are uncertain about the effects of different types of standard valves on mortality (range 2% to 17%, very low certainty of the evidence). The included studies did not report the effects of these interventions on quality of life, ventricular size reduction or head circumference. 3. Standard valve versus self-adjusting CSF flow-regulating valve One study with 229 randomised participants addressed this comparison. The incidence of treatment failure may be similar in those with standard valves (42.98%) and self-adjusting CSF flow-regulating valves (39.13%) (low certainty of the evidence). The incidence of adverse events may be similar in those with standard valves (range 0 to 1.9%) and those with self-adjusting CSF flow-regulating valves (range 0 to 7.2%) (low certainty of the evidence). The included study reported no deaths in either group in the postoperative period. Beyond the early postoperative period, the authors stated that nine patients died (no disaggregated data by each type of intervention was available, low certainty of the evidence). The included studies did not report the effects of these interventions on quality of life, ventricular size reduction or head circumference. 4. External differential programmable pressure valve versus non-programmable valve One study with 377 randomised participants addressed this comparison. The incidence of treatment failure may be similar in those with programmable valves (52%) and non-programmable valves (52%) (RR 1.02, 95% CI 0.84 to 1.24, low certainty of the evidence). The incidence of adverse events may be similar in those with programmable valves (6.19%) and non-programmable valves (6.01%) (RR 0.97, 95% CI 0.44 to 2.15, low certainty of the evidence). The included study did not report the effect of these interventions on mortality, quality of life or head circumference. Ventricular size reduction may be similar in those with programmable valves and non-programmable valves (low certainty of the evidence). AUTHORS' CONCLUSIONS Standard shunt valves for hydrocephalus compared to anti-syphon or self-adjusting CSF flow-regulating valves may cause little to no difference on the main outcomes of this review, however we are very uncertain due to the low to very low certainty of evidence. Similarly, different types of standard valves and external differential programmable pressure valves versus non-programmable valves may be associated with similar outcomes. Nevertheless, this review did not include valves with the latest technology, for which we need high-quality randomised controlled trials focusing on patient-important outcomes including costs.
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Affiliation(s)
- Luis Garegnani
- Research Department, Instituto Universitario Hospital Italiano, Buenos Aires, Argentina
| | - Juan Va Franco
- Argentine Cochrane Centre, Instituto Universitario Hospital Italiano, Buenos Aires, Argentina
| | - Agustín Ciapponi
- Argentine Cochrane Centre, Institute for Clinical Effectiveness and Health Policy (IECS-CONICET), Buenos Aires, Argentina
| | - Virginia Garrote
- Biblioteca Central, Instituto Universitario Hospital Italiano, Buenos Aires, Argentina
| | - Valeria Vietto
- Family and Community Medicine Service, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
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8
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Evaluating Shunt Survival Following Ventriculoperitoneal Shunting with and without Stereotactic Navigation in Previously Shunt-Naïve Patients. World Neurosurg 2020; 136:e671-e682. [PMID: 31996335 DOI: 10.1016/j.wneu.2020.01.138] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2019] [Revised: 01/16/2020] [Accepted: 01/18/2020] [Indexed: 11/23/2022]
Abstract
BACKGROUND Ventriculoperitoneal shunts are used to alleviate elevated intracranial pressure due to either hydrocephalus or idiopathic intracranial hypertension; however, shunt failure is a significant neurosurgical problem. Despite increases in intraoperative stereotactic navigation usage over the past decade, its effect on shunt survival remains unclear. METHODS Shunt-naïve pediatric and adult patients receiving ventriculoperitoneal shunting between 2007 and 2015 were identified in a national administrative database. Multivariable logistic and Cox regressions were used to evaluate factors affecting stereotaxy usage and shunt survival. Matched cohorts were generated by propensity score balancing. RESULTS Of 9677 patients identified, 932 received image-guided shunt placement. Total shunt failure rate was not associated with stereotaxy use (20.3% with stereotaxy vs. 19.4% without, P = 0.4602). In the matched setting, shunt survival was not extended by use of image guidance during placement (hazard ratio = 1.134, 95% confidence interval 0.923-1.393). Late shunt failures (defined as failures occurring at least 30 days after shunt placement) caused by infection occurred more frequently in the stereotaxy cohort (hazard ratio = 2.207, 95% confidence interval 1.115-4.366), whereas late shunt failures attributable to mechanical shunt failure were more common in the nonstereotaxy cohort (hazard ratio = 1.406, 95% confidence interval 1.002-1.973). CONCLUSIONS Our findings suggest stereotaxy use during ventriculoperitoneal shunt placement does not affect shunt survival. Late shunt failures caused by infection occurred more frequently in the stereotaxy cohort, whereas late failures caused by mechanical shunt malfunction were more commonly encountered in the nonstereotaxy cohort.
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Kaestner S, Poetschke M, Kehler U, Antes S, Krause M, Deinsberger W. Revision surgery following CSF shunt insertion: how often could it be avoided? Acta Neurochir (Wien) 2020; 162:9-14. [PMID: 31667581 DOI: 10.1007/s00701-019-04083-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2019] [Accepted: 09/20/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Cerebrospinal fluid (CSF) shunt revision surgery represents a huge social and economic burden. Few studies, however, have evaluated shunt revision surgeries in the context of their avoidability, and existing data are from paediatric populations. Using ratings from an expert panel, we classified avoidable and unavoidable shunt revisions in a mixed cohort of CSF-shunt patients. METHODS In a retrospective review of a prospectively maintained, single-centre database, we identified all shunt systems implanted for the first time over a 10-year period (2007-2016) and all subsequent revision surgeries with a follow-up of at least 1 year. A panel of five expert shunt surgeons classified each revision surgery as avoidable or unavoidable. Rates of each were calculated and correlated with clinical data. RESULTS Of 210 revision surgeries (314 patients, mean age, 49.9 years; mean follow-up, 4.2 years), the panel judged 114 as unavoidable (54.3%) and 96 (45.7%) as avoidable. Level of surgeon education correlated with these rates, but even in the most experienced hands, 12.5% of revisions were classified as avoidable. Avoidable revisions occurred significantly earlier than unavoidable interventions (mean; 112 and 448 days, respectively) after the index surgery. CONCLUSION Rates of avoidable shunt revision surgery are alarmingly high, even in experienced hands. Avoidable revisions occur significantly earlier, predominantly within the first 3 months after the index surgery.
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Thomale UW, Schaumann A, Stockhammer F, Giese H, Schuster D, Kästner S, Ahmadi AS, Polemikos M, Bock HC, Gölz L, Lemcke J, Hermann E, Schuhmann MU, Beez T, Fritsch M, Orakcioglu B, Vajkoczy P, Rohde V, Bohner G. GAVCA Study: Randomized, Multicenter Trial to Evaluate the Quality of Ventricular Catheter Placement with a Mobile Health Assisted Guidance Technique. Neurosurgery 2019; 83:252-262. [PMID: 28973670 PMCID: PMC6140776 DOI: 10.1093/neuros/nyx420] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Accepted: 07/25/2017] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Freehand ventricular catheter placement may represent limited accuracy for the surgeon's intent to achieve primary optimal catheter position. OBJECTIVE To investigate the accuracy of a ventricular catheter guide assisted by a simple mobile health application (mhealth app) in a multicenter, randomized, controlled, simple blinded study (GAVCA study). METHODS In total, 139 eligible patients were enrolled in 9 centers. Catheter placement was evaluated by 3 different components: number of ventricular cannulation attempts, a grading scale, and the anatomical position of the catheter tip. The primary endpoint was the rate of primary cannulation of grade I catheter position in the ipsilateral ventricle. The secondary endpoints were rate of intraventricular position of the catheter's perforations, early ventricular catheter failure, and complications. RESULTS The primary endpoint was reached in 70% of the guided group vs 56.5% (freehand group; odds ratio 1.79, 95% confidence interval 0.89-3.61). The primary successful puncture rate was 100% vs 91.3% (P = .012). Catheter perforations were located completely inside the ventricle in 81.4% (guided group) and 65.2% (freehand group; odds ratio 2.34, 95% confidence interval 1.07-5.1). No differences occurred in early ventricular catheter failure, complication rate, duration of surgery, or hospital stay. CONCLUSION The guided ventricular catheter application proved to be a safe and simple method. The primary endpoint revealed a nonsignificant improvement of optimal catheter placement among the groups. Long-term follow-up is necessary in order to evaluate differences in catheter survival among shunted patients.
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Affiliation(s)
- Ulrich-Wilhelm Thomale
- Pediatric Neurosurgery and Department of Neurosurgery, Campus Virchow Klini-kum, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Andreas Schaumann
- Pediatric Neurosurgery and Department of Neurosurgery, Campus Virchow Klini-kum, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Florian Stockhammer
- Pediatric Neurosurgery and Department of Neurosurgery, Universi-tätsmedizin Göttingen, Göttingen, Germany
| | - Henrik Giese
- Department of Neurosurgery, Universitä-tsklinikum, Heidelberg, Heidelberg, Germany
| | - Dhani Schuster
- Department of Neurosurgery, Dietrich-Bonhoeffer-Klinikum, Neubrandenburg, Germa-ny
| | | | | | - Manolis Polemikos
- Department of Neu-rosurgery, Medizinische Hochschule Hannover, Hannover, Germany
| | - Hans-Christoph Bock
- Pediatric Neurosurgery and Department of Neurosurgery, Universi-tätsmedizin Göttingen, Göttingen, Germany
| | - Leonie Gölz
- Department of Neuro-surgery, Unfallkrankenhaus, Berlin Marzahn, Berlin, Germany
| | - Johannes Lemcke
- Department of Neuro-surgery, Unfallkrankenhaus, Berlin Marzahn, Berlin, Germany
| | - Elvis Hermann
- Department of Neu-rosurgery, Medizinische Hochschule Hannover, Hannover, Germany
| | - Martin U Schuhmann
- Department of Neurosurgery, Universitätsklinikum Tübingen, Tübingen, Germany
| | - Thomas Beez
- Department of Neurosurgery, Universitätsklinikum Düsseldorf, Düsseldorf, Germany
| | - Michael Fritsch
- Department of Neurosurgery, Dietrich-Bonhoeffer-Klinikum, Neubrandenburg, Germa-ny
| | - Berk Orakcioglu
- Department of Neurosurgery, Universitä-tsklinikum, Heidelberg, Heidelberg, Germany
| | - Peter Vajkoczy
- Pediatric Neurosurgery and Department of Neurosurgery, Campus Virchow Klini-kum, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Veit Rohde
- Pediatric Neurosurgery and Department of Neurosurgery, Universi-tätsmedizin Göttingen, Göttingen, Germany
| | - Georg Bohner
- Department of Neuroradiology, Campus Virchow Klinikum, Universitätsmedizin Berlin, Berlin, Germany
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Donoho DA, Buchanan IA, Patel A, Ding L, Cen S, Wen T, Giannotta SL, Attenello F, Mack WJ. Early Readmission After Ventricular Shunting in Adults with Hydrocephalus: A Nationwide Readmission Database Analysis. World Neurosurg 2019; 128:e38-e50. [DOI: 10.1016/j.wneu.2019.03.217] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Revised: 03/20/2019] [Accepted: 03/21/2019] [Indexed: 11/29/2022]
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Lumboperitoneal and Ventriculoperitoneal Shunt Surgery for Posthemorrhagic Communicating Hydrocephalus: A Comparison. World Neurosurg 2019; 127:e638-e643. [DOI: 10.1016/j.wneu.2019.03.235] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2019] [Revised: 03/21/2019] [Accepted: 03/22/2019] [Indexed: 11/22/2022]
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Kashkoush A, Agarwal N, Ayres A, Novak V, Chang YF, Friedlander RM. Scrubbing technique and surgical site infections: an analysis of 14,200 neurosurgical cases. J Neurosurg 2019; 133:580-587. [PMID: 31200383 DOI: 10.3171/2019.3.jns1930] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2019] [Accepted: 03/15/2019] [Indexed: 12/11/2022]
Abstract
OBJECTIVE The preoperative scrub has been shown to lower the incidence of surgical site infections (SSIs). Various scrubbing and gloving techniques exist; however, it is unknown how specific scrubbing technique influences SSI rates in neurosurgery. The authors aimed to assess whether the range of scrubbing practice in neurosurgery is associated with the incidence of SSIs. METHODS The authors conducted a retrospective review of a prospectively maintained database to identify all 90-day SSIs for neurosurgical procedures between 2012 and 2017 at one of their teaching hospitals. SSIs were classified by procedure type (craniotomy, shunt, fusion, or laminectomy). Surveys were administered to attending and resident physicians to understand the variation in scrubbing methods (wet vs dry, iodine vs chlorhexidine, single vs double glove). The chi-square followed by multivariate logistic regression analyses were utilized to identify independent predictors of SSI. RESULTS Forty-two operating physicians were included in the study (18 attending physicians, 24 resident physicians), who performed 14,200 total cases. Overall, SSI rates were 2.1% (296 SSIs of 14,200 total cases) and 2.0% (192 of 9,669 cases) for attending physicians and residents, respectively. Shunts were independently associated with an increased risk of SSI (OR 1.7 [95% CI 1.3-2.1]), whereas laminectomies were associated with a decreased SSI risk (OR 0.4 [95% CI 0.2-0.8]). Wet versus dry scrub (OR 0.9 [95% CI 0.6-1.4]), iodine versus chlorhexidine (OR 0.6 [95% CI 0.4-1.1]), and single- versus double-gloving (OR 1.1 [95% CI 0.8-1.4]) preferences were not associated with SSIs. CONCLUSIONS There is no evidence to suggest that perioperative infection is associated with personal scrubbing or gloving preference in neurosurgical procedures.
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Agarwal N, Kashkoush A, McDowell MM, Lariviere WR, Ismail N, Friedlander RM. Comparative durability and costs analysis of ventricular shunts. J Neurosurg 2018:1-8. [PMID: 29749912 DOI: 10.3171/2017.11.jns172212] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2017] [Accepted: 11/10/2017] [Indexed: 11/06/2022]
Abstract
OBJECTIVEVentricular shunt (VS) durability has been well studied in the pediatric population and in patients with normal pressure hydrocephalus; however, further evaluation in a more heterogeneous adult population is needed. This study aims to evaluate the effect of diagnosis and valve type-fixed versus programmable-on shunt durability and cost for placement of shunts in adult patients.METHODSThe authors retrospectively reviewed the medical records of all patients who underwent implantation of a VS for hydrocephalus at their institution over a 3-year period between August 2013 and October 2016 with a minimum postoperative follow-up of 6 months. The primary outcome was shunt revision, which was defined as reoperation for any indication after the initial procedure. Supply costs, shunt durability, and hydrocephalus etiologies were compared between fixed and programmable valves.RESULTSA total of 417 patients underwent shunt placement during the index time frame, consisting of 62 fixed shunts (15%) and 355 programmable shunts (85%). The mean follow-up was 30 ± 12 (SD) months. The shunt revision rate was 22% for programmable pressure valves and 21% for fixed pressure valves (HR 1.1 [95% CI 0.6-1.8]). Shunt complications, such as valve failure, infection, and overdrainage, occurred with similar frequency across valve types. Kaplan-Meier survival curve analysis showed no difference in durability between fixed (mean 39 months) and programmable (mean 40 months) shunts (p = 0.980, log-rank test). The median shunt supply cost per index case and accounting for subsequent revisions was $3438 (interquartile range $2938-$3876) and $1504 (interquartile range $753-$1584) for programmable and fixed shunts, respectively (p < 0.001, Wilcoxon rank-sum test). Of all hydrocephalus etiologies, pseudotumor cerebri (HR 1.9 [95% CI 1.2-3.1]) and previous shunt malfunction (HR 1.8 [95% CI 1.2-2.7]) were found to significantly increase the risk of shunt revision. Within each diagnosis, there were no significant differences in revision rates between shunts with a fixed valve and shunts with a programmable valve.CONCLUSIONSLong-term shunt revision rates are similar for fixed and programmable shunt pressure valves in adult patients. Hydrocephalus etiology may play a significant role in predicting shunt revision, although programmable valves incur higher supply costs regardless of initial diagnosis. Utilization of fixed pressure valves versus programmable pressure valves may reduce supply costs while maintaining similar revision rates. Given the importance of developing cost-effective management protocols, this study highlights the critical need for large-scale prospective observational studies and randomized clinical trials of ventricular shunt valve revisions and additional patient-centered outcomes.
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Oushy S, Parker JJ, Campbell K, Palmer C, Wilkinson C, Stence NV, Handler MH, Mirsky DM. Frontal and occipital horn ratio is associated with multifocal intraparenchymal hemorrhages in neonatal shunted hydrocephalus. J Neurosurg Pediatr 2017; 20:432-438. [PMID: 28885094 DOI: 10.3171/2017.6.peds16481] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Placement of a cerebrospinal fluid diversion device (i.e., shunt) is a routine pediatric neurosurgical procedure, often performed in the first weeks of life for treatment of congenital hydrocephalus. In the postoperative period, shunt placement may be complicated by subdural, catheter tract, parenchymal, and intraventricular hemorrhages. The authors observed a subset of infants and neonates who developed multifocal intraparenchymal hemorrhages (MIPH) following shunt placement and sought to determine any predisposing perioperative variables. METHODS A retrospective review of the electronic medical record at a tertiary-care children's hospital was performed for the period 1998-2015. Inclusion criteria consisted of shunt placement, age < 30 days, and available pre- and postoperative brain imaging. The following data were collected and analyzed for each case: ventricular size ratios, laboratory values, clinical presentation, shunt and valve type, and operative timing and approach. RESULTS A total of 121 neonates met the inclusion criteria for the study, and 11 patients (9.1%) had MIPH following shunt placement. The preoperative frontal and occipital horn ratio (FOR) was significantly higher in the patients with MIPH than in those without (0.65 vs 0.57, p < 0.001). The change in FOR (∆FOR) after shunt placement was significantly greater in the MIPH group (0.14 vs 0.08, p = 0.04). Among neonates who developed MIPH, aqueductal stenosis was the most common etiology (45%). The type of shunt valve was associated with incidence of MIPH (p < 0.001). Preoperative clinical parameters, including head circumference, bulging fontanelle, and coagulopathy, were not significantly associated with development of MIPH. CONCLUSIONS MIPH represents an underrecognized complication of neonatal shunted hydrocephalus. Markers of severity of ventriculomegaly (FOR) and ventricular response to CSF diversion (∆FOR) were significantly associated with occurrence of MIPH. Choice of shunt and etiology of hydrocephalus were also significantly associated with MIPH. After adjusting for corrected age, etiology of hydrocephalus, and shunt setting, the authors found that ∆FOR after shunting was still associated with MIPH. A prospective study of MIPH prevention strategies and assessment of possible implications for patient outcomes is needed.
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Affiliation(s)
| | - Jonathon J Parker
- Department of Neurosurgery, Stanford University, Stanford, California
| | - Kristen Campbell
- Child Health Research Biostatistical Core, Children's Hospital Colorado; and.,Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, Colorado; and
| | - Claire Palmer
- Pediatrics, University of Colorado School of Medicine.,Child Health Research Biostatistical Core, Children's Hospital Colorado; and
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Kaestner S, Poetschke M, Roth C, Deinsberger W. Different origins of hydrocephalus lead to different shunt revision rates. Neurol Neurochir Pol 2017; 51:72-76. [PMID: 28063609 DOI: 10.1016/j.pjnns.2016.11.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Revised: 08/20/2016] [Accepted: 11/20/2016] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Hydrocephalus (HC) occurs due to multiple origins. Time course and dynamic of HC and its therapies differ between underlying pathologies. Different revision rates due to the type of HC are expected. Though hydrocephalus is known to be a life time condition, the lack of shunt malfunction years or decades after initial shunt insertion raises the hope of a superfluous shunt. METHODS We conducted a retrospective survey of our OR-database during a 10 year period. All newly inserted shunt systems and subsequent shunt revisions are recorded according to quantity and time point. All patients were subdivided according their aetiology of HC. RESULTS 260 patients were eligible with a follow-up of 4.5 years. Subgroups were: 90 patients with NPH, 76 patients with posthaemorrhagic and 16 patients had posttraumatic HC. 22 received a shunt as a consequence of a tumour, 41 were children and 15 for other causes. Overall revision rate was 39.5%. During the first 6 months 55.6%, 57.9% and 75% of patients with NPH, posthaemorrhagic and posttraumatic HC had revisions. In contrast only 38.1% of children and 20% of tumour cases required early revision. CONCLUSION Two different patterns of revision are evident: mainly early revisions in morphologically stable diseases such as posthaemorrhagic, posttraumatic and NPH and predominantly late revisions in changing organisms such as children and tumour patients. The conception HC may be transient because of a lack of late revisions cannot be supported by this data.
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Affiliation(s)
| | - Manuela Poetschke
- Applied Statistics, Department 05, University of Kassel, Kassel, Germany
| | - Christian Roth
- Department of Neurology, Klinikum Kassel, Kassel, Germany
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He M, Ouyang L, Wang S, Zheng M, Liu A. Laparoscopy versus mini-laparotomy peritoneal catheter insertion of ventriculoperitoneal shunts: a systematic review and meta-analysis. Neurosurg Focus 2016; 41:E7. [DOI: 10.3171/2016.5.focus1637] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE
Ventriculoperitoneal (VP) shunt treatment is the main treatment method for hydrocephalus. The traditional operative approach for peritoneal catheter insertion is mini-laparotomy. In recent years, laparoscopy-assisted insertion has become increasingly popular. It seems likely that use of an endoscope could lower the incidence of shunt malfunction. However, there is no consensus about the benefits of laparoscopy-assisted peritoneal catheter insertion.
METHODS
A systematic search was performed using the PubMed, Embase, ScienceDirect, and Cochrane Library databases. A manual search for reference lists was conducted. The protocol was prepared according to the interventional systematic reviews of the Cochrane Handbook, and the article was written on the basis of the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) guidelines.
RESULTS
Eleven observational trials and 2 randomized controlled trials were included. Seven operation-related outcome measures were analyzed, and 3 of these showed no difference between operative techniques. The results of the meta-analysis are as follows: in the laparoscopy group, the rate of distal shunt failure was lower (OR 0.41, 95% CI 0.25–0.67; p = 0.0003), the absolute effect is 7.11% for distal shunt failure, the number needed to treat is 14 (95% CI 8–23), operative time was shorter (mean difference [MD], −12.84; 95% CI −20.68 to −5.00; p = 0.001), and blood loss was less (MD −9.93, 95% CI −17.56 to −2.31; p = 0.01). In addition, a borderline statistically significant difference tending to laparoscopic technique was observed in terms of hospital stay (MD −1.77, 95% CI −3.67 to 0.13; p = 0.07).
CONCLUSIONS
To some extent, a laparoscopic insertion technique could yield a better prognosis, mainly because it is associated with a lower distal failure rate and shorter operative time, which would be clinically relevant.
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Abstract
Ventricular shunts are mechanical devices used in the treatment of hydrocephalus, by means of which cerebrospinal fluid (CSF) is diverted from the ventricles to other low-pressure body cavities. Over the last 50 years, mechanical shunting has become the cornerstone for the treatment of hydrocephalus with shunt valves evolving from simple differential valves to complex programmable valves. The chief complications of ventricular shunting include obstruction, infections, and overdrainage causing subdural hematomas and slit-ventricle syndrome. As the number of commercially available valve designs continues to grow, each new generation aims at reducing the likelihood of complications, especially those resulting from overdrainage. Several studies aimed at establishing the superiority of any valve design have been conducted. All have highlighted the advantages and shortcomings of most models without conclusively providing evidence for choosing one over another. As a result, choices still rest on individual and institutional preferences.
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Bir SC, Sapkota S, Maiti TK, Konar S, Bollam P, Nanda A. Evaluation of Ventriculoperitoneal Shunt-Related Complications in Intracranial Meningioma with Hydrocephalus. J Neurol Surg B Skull Base 2016; 78:30-36. [PMID: 28180040 DOI: 10.1055/s-0036-1584309] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2014] [Accepted: 04/19/2016] [Indexed: 10/21/2022] Open
Abstract
Objective Meningioma is a common intracranial tumor that predisposes patients to hydrocephalus which may require a permanent cerebrospinal fluid (CSF) diversion procedure such as ventriculoperitoneal (VP) shunts. We reviewed our long-term experience with VP shunts for the management of hydrocephalus in patients with meningioma. Methods and Materials A total of 48 Patients with meningioma who underwent VP shunt insertion for hydrocephalus from 1990 to 2013 was included in our case series. The study population was evaluated clinically and radiographically after VP shunt placement. Results Overall shunt failure was seen in 13 (27%) patients. Single and multiple shunt revisions were required in eight (16.7%) and five (10.4%) patients, respectively. The overall shunt revision within 6 months, 1 , and 5 years was 19, 23, and 27%, respectively. Male patient was significantly associated with the longer survival after shunt placement. Revisions free survival after 3, 5, 10, and 15 years of VP shunt placement were 70, 46, 30, and 20%, respectively. Finally, in regression analysis, age greater than 65 years (p = 0.02, 95% confidence interval (CI) = 0.1-0.13), tumor in posterior fossa (p < 0.0001, 95% CI = 0.1-0.23), tumor size (> 5 cm) (p = 0.3, 95% CI = 0.01-0.19), and Simpson resection grades II to IV (p = 0.04, 95% CI = 0.07-0.2) were identified as positive predictors of requirement of CSF flow diversion Conclusion The findings of the present study reveal that VP shunting is an important treatment option for the management of hydrocephalus in patients with meningioma. Further studies using less invasive techniques are warranted to compare the benefits of VP shunt for the management of hydrocephalus.
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Affiliation(s)
- Shyamal C Bir
- Department of Neurosurgery, Louisiana State University Health-Shreveport, Shreveport, Louisiana, United States
| | - Shabal Sapkota
- Department of Neurosurgery, Louisiana State University Health-Shreveport, Shreveport, Louisiana, United States
| | - Tanmoy K Maiti
- Department of Neurosurgery, Louisiana State University Health-Shreveport, Shreveport, Louisiana, United States
| | - Subhas Konar
- Department of Neurosurgery, Louisiana State University Health-Shreveport, Shreveport, Louisiana, United States
| | - Papireddy Bollam
- Department of Neurosurgery, Louisiana State University Health-Shreveport, Shreveport, Louisiana, United States
| | - Anil Nanda
- Department of Neurosurgery, Louisiana State University Health-Shreveport, Shreveport, Louisiana, United States
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Coulibaly O, Dama M, Diallo O, Li G, Sogoba Y, Kanikomo D. Delayed intracerebral and subdural hematomas after ventriculo-peritoneal shunt in a child: A case report and review of the literature. Neurochirurgie 2016; 62:105-7. [DOI: 10.1016/j.neuchi.2016.01.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2015] [Revised: 12/27/2015] [Accepted: 01/10/2016] [Indexed: 02/06/2023]
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Gerner ST, Kuramatsu JB, Abel H, Kloska SP, Lücking H, Eyüpoglu IY, Doerfler A, Schwab S, Huttner HB. Intraventricular fibrinolysis has no effects on shunt dependency and functional outcome in endovascular-treated aneurysmal SAH. Neurocrit Care 2015; 21:435-43. [PMID: 24566979 DOI: 10.1007/s12028-014-9961-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Intraventricular fibrinolysis (IVF) in subarachnoid hemorrhage (SAH) is an emerging strategy aiming to hasten clot lysis, treat hydrocephalus, and reduce permanent shunt rates. Because of clinical heterogeneity of investigated patient effects of IVF on permanent shunt incidence and functional outcome are widely debated. The present study is the first to investigate solely endovascular-treated SAH patients. METHODS Overall, 88 consecutive patients with aneurysmal SAH requiring external ventricular drain placement and endovascular aneurysm closure were included. Functional outcome and shunt dependency were assessed 90 days after event. A matched controlled sub-analysis was carried out to investigate the effects of IVF treatment (n = 14; matching criteria: age, neuro-status and imaging). Multivariate modeling was performed to identify independent predictors for permanent shunt dependency. RESULTS In IVF-patients neurological status was significantly poorer [Hunt&Hess: IVF = 4(3-5) vs. non-IVF = 3(1-5); p = 0.035] and the extent of ventricular hemorrhage was increased [Graeb Score: IVF = 7(6-8) vs. non-IVF = 3(1-4); p ≤ 0.001]. Consecutive matched controlled sub-analysis revealed no significant therapeutic effect of IVF with respect to shunt dependency rate and functional outcome. Multivariate analysis revealed Graeb score [OR = 1.34(1.02-1.76); p = 0.035] and sepsis [OR = 11.23(2.28-55.27); p = 0.003] as independent predictors for shunt dependency, whereas IVF did not exert significant effects (p = 0.820). CONCLUSIONS In endovascular-treated SAH patients IVF neither reduced permanent shunt dependency nor influenced functional outcome. Despite established effects on intraventricular clot resolution IVF appears less powerful in SAH as compared to ICH. Given the reported positive effects of lumbar drainage (LD) in SAH, a prospective analysis of a combined treatment approach of IVF and subsequent lumbar drain sOeems warranted aiming to reduce permanent shunting and improve functional outcome.
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Affiliation(s)
- Stefan T Gerner
- Department of Neurology, University of Erlangen-Nuremberg, Schwabachanlage 6, 91054, Erlangen, Germany
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Zheng XR, Chen T, Yang YF, Rao W, Wang GY, Zhang SH, Fei Z. Unplanned Reoperations in Neurosurgical Patients Due to Postoperative Bleeding: A Single-Center Experience and Literature Review. Medicine (Baltimore) 2015; 94:e739. [PMID: 26061301 PMCID: PMC4616491 DOI: 10.1097/md.0000000000000739] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
The aim of this study is to investigate the incidence of unplanned reoperations from all causes due to bleeding in neurosurgical patients. The medical records of patients who received neurosurgical procedures at our hospital were retrospectively reviewed and data of patients who received reoperations were extracted and summarized. A literature review was conducted of the Medline, Cochrane, EMBASE, and Google Scholar databases up to November 2013. The main outcome measure was the rate of unplanned reoperations due to bleeding. At our hospital, 68 patients with a mean age of 41.5 ± 21.5 years (range, 7 months to 76 years) received an unplanned reoperation. More than 70% of the patients were older than 18 years, 64.7% were males, and 94.1% had cranial surgery. Almost 60% of the patients received >1 blood transfusion (58.8%) after the first surgery. Of the 68 patients, 35 (51.5%) received a second operation due to bleeding. Univariate logistic regression analysis only showed that an increasing time interval between the first and second surgery was associated with a decreased chance of the reoperation being performed due to bleeding (odds ratio [OR] = 0.843, 95% confidence interval [CI]: 0.720-0.987; P = .033). Of 229 studies identified, 5 retrospective reports with a total of 1375 patients were included in the analysis. The rate of reoperations for bleeding in the 5 studies ranged from 4.2% to 31.5%. Employing measures to reduce postoperative bleeding may help reduce the rate of unplanned neurosurgical reoperations.
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Affiliation(s)
- Xin-Rui Zheng
- From the Department of Neurosurgery (X-RZ, TC, Y-FY, WR, ZF); Department of Medical affairs and training, Xijing Hospital, Fourth Military Medical University, Xi'an, Shanxi, PR China (G-YW, S-HZ)
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Low YYS, Thomas J, Wan WK, Ng WH. Brain metastases as a cause of malignant cerebrospinal fluid ascites: case report and review of the literature. CNS Oncol 2015; 1:29-37. [PMID: 25054298 DOI: 10.2217/cns.12.2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
The development of cerebrospinal fluid ascites after a ventriculo-peritoneal shunt operation is an extremely rare complication. There have been only sporadic case reports and small series reviews published in regards to this condition. They are usually found in the context of primary brain tumors, usually affecting the pediatric population. We present an unusual case of a patient with known metastatic breast carcinoma to the brain who develops malignant cerebrospinal fluid ascites after a ventriculo-peritoneal shunt insertion. This is the first known adult case of a metastatic breast primary to the brain causing tumor dissemination via a ventriculo-peritoneal shunt.
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Affiliation(s)
- Yin Yee Sharon Low
- Department of Neurosurgery, National Neuroscience Institute, 11, Jalan Tan Tock Seng, 308433, Singapore
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24
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Khan F, Rehman A, Shamim MS, Bari ME. Factors affecting ventriculoperitoneal shunt survival in adult patients. Surg Neurol Int 2015; 6:25. [PMID: 25722930 PMCID: PMC4338490 DOI: 10.4103/2152-7806.151388] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2014] [Accepted: 10/09/2014] [Indexed: 11/07/2022] Open
Abstract
Background: Ventriculoperitoneal (VP) shunt insertion remains the mainstay of treatment for hydrocephalus despite a high rate of complications. The predictors of shunt malfunction have been studied mostly in pediatric patients. In this study, we report our 11-year experience with VP shunts in adult patients with hydrocephalus. We also assess the various factors affecting shunt survival in a developing country setting. Methods: A retrospective chart analysis was conducted for all adult patients who had undergone shunt placement between the years 2001 and 2011. Kaplan–Meier curves were used to determine the duration from shunt placement to first malfunction and log-rank (Cox–Mantel) tests were used to determine the factors affecting shunt survival. Results: A total of 227 patients aged 18–85 years (mean: 45.8 years) were included in the study. The top four etiologies of hydrocephalus included post-cranial surgery (23.3%), brain tumor or cyst (22.9%), normal pressure hydrocephalus (15%), and intracranial hemorrhage (13.7%). The overall incidence of shunt malfunction was 15.4% with the median time to first shunt failure being 120 days. Etiology of hydrocephalus (P = 0.030) had a significant association with the development of shunt malfunction. Early shunt failure was associated with age (P < 0.001), duration of hospital stay (P < 0.001), Glasgow Coma Scale (GCS) score less than 13 (P = 0.010), excision of brain tumors (P = 0.008), and placement of extra-ventricular drains (P = 0.033). Conclusions: Patients with increased age, prolonged hospital stay, GCS score of less than 13, extra-ventricular drains in situ, or excision of brain tumors were more likely to experience early shunt malfunction.
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Affiliation(s)
- Farid Khan
- Department of Surgery, The Aga Khan University, Stadium Road, Karachi, Sindh, Pakistan
| | - Abdul Rehman
- Department of Biological and Biomedical Sciences, The Aga Khan University, Stadium Road, Karachi, Sindh, Pakistan
| | - Muhammad S Shamim
- Department of Surgery, The Aga Khan University, Stadium Road, Karachi, Sindh, Pakistan
| | - Muhammad E Bari
- Department of Surgery, The Aga Khan University, Stadium Road, Karachi, Sindh, Pakistan
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Choi JW, Kim SK, Wang KC, Lee JY, Cheon JE, Phi JH. Multifocal intraparenchymal hemorrhages after ventriculoperitoneal shunt surgery in infants. J Neurosurg Pediatr 2014; 14:329-35. [PMID: 25062301 DOI: 10.3171/2014.6.peds13635] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Ventriculoperitoneal (VP) shunt surgery is the most common treatment for hydrocephalus. In certain situations, uncommon complications can occur after shunting procedures. The authors undertook this study to analyze the clinical characteristics of pediatric patients who developed multifocal intraparenchymal hemorrhages (MIPHs) as a complication of shunt surgery. The authors also analyzed the risk factors for MIPH in a large cohort of patients with hydrocephalus. METHODS This study included all pediatric patients (age < 18 years) who underwent VP shunt surgery at the authors' institution between January 2001 and December 2012. During this period, 507 VP shunt operations were performed in 330 patients. Four of these patients were subsequently diagnosed as having MIPH. The authors analyzed the clinical characteristics of these patients in comparison with those of the entire group of shunt-treated patients. RESULTS The incidence of MIPH was 1.2% (4 of 330 cases) for all pediatric patients who underwent VP shunt placement but 2.9% (4 of 140 cases) for infants less than 1 year old. When the analysis was limited to patients whose corrected age was less than 3 months, the incidence was 5.3% (4 of 76 cases). Of the 4 patients with MIPH, 2 were male and 2 were female. Their median age at surgery was 54 days (range 25-127 days), and in all 4 cases, the patients' corrected age was less than 1 month. Three patients were preterm infants, whereas one patient was full-term. None of these patients had a prior history of intracranial surgery (including CSF diversion procedures). All showed severe hydrocephalus during the preoperative period. Their clinical courses as patients with MIPH were comparatively favorable, despite the radiological findings. CONCLUSIONS MIPH is a rare but not negligible complication of VP shunt surgery. This complication might be a unique phenomenon in infants, especially young, preterm infants with severe hydrocephalus. Moreover, the absence of previous intracranial procedures might be one of the risk factors for this complication. The rapid alteration of brain conditions in the setting of immaturity might cause MIPH. To prevent this complication, the authors recommend that pressure settings of programmable valves should be gradually adapted to the target pressure.
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Young AE. Designing a safe and sustainable pediatric neurosurgical practice: the English experience. Paediatr Anaesth 2014; 24:649-56. [PMID: 24924338 DOI: 10.1111/pan.12453] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/13/2014] [Indexed: 11/28/2022]
Abstract
The 2001 Report of the Public Inquiry into children's heart surgery at the Bristol Royal Infirmary 1984-1995 stated that there must be standards for hospitals as a whole and that hospitals, which do not meet these standards, should not be able to offer services within the National Health Service (NHS). In 2013, agreed standards for pediatric neurosurgery were produced. Between 2001 and 2013 several key documents were published, which formed the background to the review that produced these standards:, the 'Safe and Sustainable' review. The process had the mission statement, 'Safe, sustainable and world class. Not ordinary, OK or just good enough.' In April 2013, the new commissioning structure of NHS England came into being. Clinical Reference Groups (reporting directly into the new structure) and pediatric neurosurgical operational delivery networks are taking the Safe and Sustainable pediatric neurosurgery standards and models of care into practice in England. Effective outcome data collection will allow us to assess whether these networks will improve equity of access for English children to world-class pediatric neurosurgical care and reduce the variation in outcomes seen at the present time.
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Affiliation(s)
- Amber E Young
- Department of Anaesthesia, Bristol Royal Hospital for Children, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
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Coulter IC, Pesic-Smith JD, Cato-Addison WB, Khan SA, Thompson D, Jenkins AJ, Strachan RD, Mukerji N. Routine but risky: a multi-centre analysis of the outcomes of cranioplasty in the Northeast of England. Acta Neurochir (Wien) 2014; 156:1361-8. [PMID: 24752723 DOI: 10.1007/s00701-014-2081-1] [Citation(s) in RCA: 74] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2013] [Accepted: 03/25/2014] [Indexed: 11/28/2022]
Abstract
BACKGROUND Cranioplasty is undertaken as a routine secondary operation following craniectomy. At a time when decompressive craniectomy is being evaluated by several large trials, we aimed to evaluate the morbidity associated with cranioplasty and investigate its potential effect on outcome. METHODS The outcomes of 166 patients undergoing cranioplasty at two centres in the United Kingdom between June 2006 and September 2011 were retrospectively analysed. Outcome measures included mortality, morbidity and functional outcome determined by the modified Rankin score (mRS) at last follow-up. A logistic regression analysis was performed to model and predict determinants related to neurological outcome following cranioplasty. RESULTS Sixty-seven out of 166 patients (40.4 %) experienced at least one complication during a median follow-up time of 15 months (inter-quartile range 5-38 months). Thirty six patients (21.7 %) developed infection requiring antibiotics, with 27 (16.3 %) requiring removal of the cranioplasty. Nine of 25 patients (36 %) with bi-frontal defects developed an infection whereas 21 of the 153 patients (16.4 %) with a defect other than bi-frontal developed an infection (Chi square p = 0.009). Further surgery in the two groups was required in 16.4 % and 11.7, % respectively. Pseudomeningocoele (9 %), seizures (8.4 %) and poor cosmesis (7.2 %) were also commonly observed. Logistic regression analysis identified initial operation (p < 0.03), mRS at the time of cranioplasty (p < 0.0001) and complications (p < 0.04) as being predictive of neurological outcome at last follow-up. Age at the time of cranioplasty and the timing of cranioplasty were not predictive of last mRS score at follow-up. CONCLUSIONS Cranioplasty harbours significant morbidity, a risk that appears to be higher with a bifrontal defect. The complications experienced influence subsequent functional outcome. The timing of cranioplasty, early or late, after the initial operation does not impact on the ultimate outcome. These findings should be considered when making decisions relating to craniectomy and cranioplasty.
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Affiliation(s)
- Ian C Coulter
- Department of Neurosurgery, James Cook University Hospital, Middlesbrough, TS4 3BW, UK,
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Gliemroth J, Käsbeck E, Kehler U. Ventriculocisternostomy versus ventriculoperitoneal shunt in the treatment of hydrocephalus: a retrospective, long-term observational study. Clin Neurol Neurosurg 2014; 122:92-6. [PMID: 24908225 DOI: 10.1016/j.clineuro.2014.03.022] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2014] [Revised: 03/16/2014] [Accepted: 03/18/2014] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The goal of this study was the retrospective analysis of long-term data on endoscopic ventriculocisternostomy versus ventriculoperitoneal shunt placement in the treatment of hydrocephalus. METHODS A total of 159 patients were included in the study. One hundred and twenty-three patients received a ventriculoperitoneal shunt, whereas 36 patients were treated with an endoscopic procedure. Only patients with a postoperative observation period of at least 3 years were included in the analyses of the long-term data. In addition to general patient and operation data, the number and frequency of perioperative complications (infections, dysfunctions) and the frequency and type of necessary revision operations were collected. RESULTS The average observation period was 69 months for both groups. The risk of operative revision was significantly elevated in the shunt group despite a comparable observation period. Whereas 86.11% of the endoscopy group did not require an operative revision, that only applied to 68.85% of the shunt group. The complication rate was 42.7% in the shunt group per procedure, which was clearly higher than in the endoscopy group at only 9.4%. CONCLUSION The risk of operative revision and/or complications is significantly lower in the endoscopic ventriculocisternostomy group compared to the ventriculoperitoneal shunt group. Given the appropriate indication, endoscopic ventriculocisternostomy is thus the treatment of choice.
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Affiliation(s)
- Jan Gliemroth
- Department of Neurosurgery, University of Lübeck, Lübeck, Germany.
| | - Eva Käsbeck
- Medical Clinic 3, HELIOS Clinic, Wuppertal, Germany
| | - Uwe Kehler
- Department of Neurosurgery, Asklepios Clinic, Altona, Germany
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Ziebell M, Wetterslev J, Tisell M, Gluud C, Juhler M. Flow-regulated versus differential pressure-regulated shunt valves for adult patients with normal pressure hydrocephalus. Cochrane Database Syst Rev 2013:CD009706. [PMID: 23728696 DOI: 10.1002/14651858.cd009706.pub2] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Since 1965 many ventriculo-peritoneal shunt systems have been inserted worldwide to treat hydrocephalus. The most frequent indication in adults is normal pressure hydrocephalus (NPH), a condition that can be difficult to diagnose precisely. Surgical intervention with flow-regulated and differential pressure-regulated ventriculo-peritoneal shunts remains controversial. Knowledge about the benefits and harms of these interventions is limited. OBJECTIVES The objective of this review is to summarize the evidence on benefits and harms of flow-regulated versus differential pressure-regulated shunt valves for adult patients with NPH, based on reported findings of randomised clinical trials. SEARCH METHODS The ALOIS (www.medicine.ox.ac.uk/alois), the Cochrane Dementia and Cognitive Improvement Group Specialized Register; MEDLINE (from 1950) (Ovid SP); EMBASE (from 1980) (Ovid SP); CINAHL (from 1980) (EBSCOhost); PsycINFO (from 1806) (Ovid SP); LILACS (from 1982 ) (BIREME); ClinicalTrials.gov; Umin Japan Trial Register; WHO portal;The Cochrane Library's Central Register of Controlled trials (CENTRAL); ISI Web of Knowledge Conference Proceedings; Index to Theses; and Australasian Digital Theses were searched until May 16, 2012.The search terms used were NPH, "normal pressure hydrocephalus," iNPH, idiopathic normal pressure hydrocephalus, sNPH, and "secondary normal pressure hydrocephalus." SELECTION CRITERIA We planned to include randomised clinical trials comparing flow-regulated versus differential pressure-regulated shunt valves. DATA COLLECTION AND ANALYSIS Two authors with expert knowledge within the field independently reviewed studies for eligibility, assessed risk of bias, and extracted data. MAIN RESULTS No randomised clinical trials comparing flow-regulated versus differential pressure-regulated shunt valves were found. AUTHORS' CONCLUSIONS There is no evidence from randomised clinical trials indicates that flow-regulated and differential pressure-regulated shunt valves differ with regard to clinical outcome, shunt failure, or intervention risks. Randomised clinical trials are needed that take into account the large number of VP shunts implanted each year in patients with NPH.
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Affiliation(s)
- Morten Ziebell
- Department of Neurosurgery, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.
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30
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Reddy GK, Bollam P, Caldito G. Long-term outcomes of ventriculoperitoneal shunt surgery in patients with hydrocephalus. World Neurosurg 2013; 81:404-10. [PMID: 23380280 DOI: 10.1016/j.wneu.2013.01.096] [Citation(s) in RCA: 218] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2012] [Revised: 11/15/2012] [Accepted: 01/25/2013] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Ventriculoperitoneal (VP) shunt surgery is the predominant mode of therapy for patients with hydrocephalus. However, it has potential complications that may require multiple surgical procedures during a patient's lifetime. The objective of this study is to review our long-term experience and evaluate the risk factors for VP shunt failure after initial shunt surgery and after subsequent revisions. METHODS Patients who underwent VP shunt surgery for hydrocephalus were included. Medical charts, operative reports, imaging studies, and clinical follow-up evaluations were reviewed and analyzed retrospectively. RESULTS A total of 1015 patients with the median age of 41.6 (range, 0-90.3) years at the time of VP shunt surgery were included. The mean and median follow up was 9.2 and 6.5 years, respectively. Adult patients (≥ 17 years) accounted for 70.0% of the patients. The overall shunt failure rate requiring shunt revision(s) was 46.3%, and the majority of shunt revisions occurred during the first 6 months after shunt placement. The shunt revision rate was significantly greater in pediatric (<17 years) than in adult (>17 years) patients (78.2% vs. 32.5%, P < 0.001). Age at the time of shunt surgery, previous treatments to shunt surgery, etiology of hydrocephalus, and hydrocephalus type were independently associated with the incidence of shunt revision. Age at shunt placement and sex were significantly associated with multiple shunt revisions. Among populations with at least one shunt revision, pediatric patients had significantly lower shunt survival rate and shorter median time to subsequent shunt revision than the adult (>17 years) patients; male patients had greater odds for multiple revisions than female patients. CONCLUSION The findings of the study indicate that age at shunt placement, etiology of hydrocephalus, type of hydrocephalus, and previous treatments before shunt surgery were independently significantly associated with the shunt survival. Prospective controlled studies are required to address the observed associations between the risk factors and incidence of shunt revisions in these patients.
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Affiliation(s)
- G Kesava Reddy
- Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA.
| | - Papireddy Bollam
- Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA
| | - Gloria Caldito
- Department of Bioinformatics and Computational Biology, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA
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Reddy GK, Bollam P, Caldito G, Guthikonda B, Nanda A. Ventriculoperitoneal shunt surgery outcome in adult transition patients with pediatric-onset hydrocephalus. Neurosurgery 2012; 70:380-8; discussion 388-9. [PMID: 21841526 DOI: 10.1227/neu.0b013e318231d551] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Ventriculoperitoneal shunting remains the most widely used neurosurgical procedure for the management of hydrocephalus, albeit with many complications. OBJECTIVE To review and assess the long-term clinical outcome of ventriculoperitoneal shunt surgery in adult transition patients with pediatric-onset hydrocephalus. METHODS Patients 17 years or older who underwent ventriculoperitoneal shunt placement for hydrocephalus during their pediatric years (younger than 17 years) were included. Medical charts, operative reports, imaging studies, and clinical follow- up evaluations were reviewed and analyzed retrospectively. RESULTS A total of 105 adult patients with pediatric-onset hydrocephalus were included. The median age of the patients was 25.9 years. The median age at the time of the initial ventriculoperitoneal shunt placement was 1.0 year. The median follow-up time for all patients was 17.7 years. The incidence of shunt failure at 6 months was 15.2%, and the overall incidence of shunt failure was 82.9%. Single shunt revision occurred in 26.7% of the patients, and 56.2% had multiple shunt revisions. The cause of hydrocephalus was significantly associated with shunt survival for patients who had shunt failure before the age of 17 years. Being pediatric at first shunt revision, infection, proximal shunt complication, and other causes were independently associated with multiple shunt failures. CONCLUSION The findings of this retrospective study show that the long-term ventriculoperitoneal shunt survival remains low in adult transition patients with pediatric-onset hydrocephalus.
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Affiliation(s)
- G Kesava Reddy
- Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana 71103-33932, USA.
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Reddy GK. Ventriculoperitoneal shunt surgery and the incidence of shunt revision in adult patients with hemorrhage-related hydrocephalus. Clin Neurol Neurosurg 2012; 114:1211-6. [PMID: 22472352 DOI: 10.1016/j.clineuro.2012.02.050] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2011] [Revised: 02/16/2012] [Accepted: 02/20/2012] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Ventriculoperitoneal shunt surgery remains the most widely accepted neurosurgical procedure for the management of hydrocephalus. However, shunt failure and complications are common and may require multiple surgical procedures during a patient's lifetime. The purpose of this study is to evaluate the ventriculoperitoneal shunt surgery and the incidence of shunt revision in adult patients with hemorrhage-related hydrocephalus. METHODS Adult patients who underwent ventriculoperitoneal shunt placement for hemorrhage-related hydrocephalus from October 1990 to October 2009 were included in this study. Medical charts, operative reports, imaging studies, and clinical follow-up evaluations were reviewed and analyzed retrospectively. RESULTS A total of 133 adult patients with the median age of 54.5 years were included. Among patients, 41% were males, and 62% Caucasians. The overall shunt revision rate was 51.9%. The shunt revision rate within the first 6 months after the initial placement of ventriculoperitoneal shunts was 45.1%. The median time to first shunt revision was 0.50 (95% CI, 0.24-9.2) months. No significant association was observed between perioperative variables (gender, ethnicity, hydrocephalus type, or hemorrhage type) and the shunt revision rate in these patients. Major causes of shunt revision include infection (3.6%), overdrainage (7.6%), obstruction (4.8%), proximal shunt complication (7.6%), distal shunt complication (3.6%), old shunt dysfunction (6.8%), valve malfunction (10.0%), externalization (3.6%), shunt complication (12.0%), shunt adjustment/replacement (24.0%) and other (16.4%). CONCLUSION Although ventriculoperitoneal shunting remains to be the treatment of choice for adult patients with post hemorrhage-related hydrocephalus, a thorough understanding of predisposing factors related to the shunt failure is necessary to improve treatment outcomes.
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Affiliation(s)
- G Kesava Reddy
- Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, LA 71103, United States.
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Zhou F, Liu Q, Ying G, Zhu X. Delayed intracerebral hemorrhage secondary to ventriculoperitoneal shunt: two case reports and a literature review. Int J Med Sci 2012; 9:65-7. [PMID: 22219712 PMCID: PMC3245413 DOI: 10.7150/ijms.9.65] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2011] [Accepted: 11/20/2011] [Indexed: 11/07/2022] Open
Abstract
Ventriculoperitoneal (VP) shunt has become a popular operation to achieve cerebrospinal fluid (CSF) diversion, but is associated with many complications. Postoperative delayed intracerebral hemorrhage is a kind of rare but severe event, which has not thus far been reported in retrospective case analyses. Here we present two cases of delayed intracerebral hemorrhage, along the path of the ventricular catheter, which occurred on postoperative days 3 and 5. We also provide a literature review regarding this rare complication.
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Affiliation(s)
- Feng Zhou
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, China
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Reddy GK, Bollam P, Shi R, Guthikonda B, Nanda A. Management of adult hydrocephalus with ventriculoperitoneal shunts: long-term single-institution experience. Neurosurgery 2011; 69:774-80; discussion 780-1. [PMID: 21508873 DOI: 10.1227/neu.0b013e31821ffa9e] [Citation(s) in RCA: 73] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Ventriculoperitoneal shunting is the most widely used neurosurgical procedure for the management of hydrocephalus. OBJECTIVE To evaluate our long-term single-institution experience in the management of adult hydrocephalus patients with ventriculoperitoneal shunts. METHODS Adult patients who underwent ventriculoperitoneal shunt placement for hydrocephalus from October 1990 to October 2009 were included. Medical charts, operative reports, imaging studies, and clinical follow-up evaluations were reviewed and analyzed retrospectively for clinical outcome in adult hydrocephalus patients. RESULTS A total of 683 adult patients were included in the study. The most common etiologies of hydrocephalus include idiopathic (29%), tumors and cysts (20%), postcraniotomy (13%), and subarachnoid hemorrhage (13%). The overall shunt failure rate was 32%, and the majority (74%) of shunt revisions occurred within the first 6 months. The median time to first shunt revision was 9.31 months. Etiology of hydrocephalus showed a significant impact on the incidence of shunt revision/failure and on the median time to shunt revision. Similarly, the type of hydrocephalus had a significant effect on the incidence of shunt failure and the median time to shunt revision. CONCLUSION A large proportion of patients (32%) experience shunt failure after shunt placement for hydrocephalus. Although the overall incidence of shunt revision was comparable to previously reported studies, the fact that a large proportion of adult populations with shunt placement experience shunt failure is a concern.
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Affiliation(s)
- G Kesava Reddy
- Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, LA, USA.
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Naftel RP, Argo JL, Shannon CN, Taylor TH, Tubbs RS, Clements RH, Harrigan MR. Laparoscopic versus open insertion of the peritoneal catheter in ventriculoperitoneal shunt placement: review of 810 consecutive cases. J Neurosurg 2011; 115:151-8. [DOI: 10.3171/2011.1.jns101492] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Traditional ventriculoperitoneal (VP) shunt surgery involves insertion of the distal catheter by minilaparotomy. However, minilaparotomy may be a significant source of morbidity during shunt surgery. Laparoscopic insertion of the distal catheter is an alternative technique that may simplify and improve the safety of shunt surgery.
Methods
The authors performed a retrospective review of hospital records of all patients undergoing new VP shunt insertion at a tertiary care center between 2004 and 2009. Patient characteristics and outcomes were compared between patients undergoing open or laparoscopic insertion of the distal catheter. Independent variables in the analysis included age, sex, race, body mass index, surgical technique, previous VP shunt placement, previous abdominal procedures, American Society of Anesthesiology (ASA) score, and indication for shunt placement. Dependent variables included the occurrence of shunt failure, cause of shunt failure, complications, length of stay (LOS), LOS after shunt placement, estimated blood loss, and operative time.
Results
The authors identified 810 patients who met the inclusion criteria; open or laparoscopic distal catheter insertion was performed in 335 and 475 patients, respectively. There were no significant differences between the groups regarding age, race, ASA score, or indication for shunt placement. The most common indication was hydrocephalus due to subarachnoid hemorrhage, followed by tumor-associated hydrocephalus, normal pressure hydrocephalus (NPH), and hydrocephalus due to trauma. The incidence of shunt failure was not statistically different between cohorts, occurring in 20.0% of laparoscopic and 20.9% of open catheter placement cases (p = 0.791). With analysis of causes of shunt failure, shunt obstruction occurred significantly more often in the open surgery cohort (p = 0.012). In patients with a known cause shunt obstruction, distal obstruction occurred in 35.7% of the open cohort obstructions and 4.8% of the laparoscopic cohort obstructions (p = 0.014). The relative risk of distal obstruction in open cases compared with laparoscopic cases was 7.50. Infections occurred in 8.2% of laparoscopic cases compared with 6.6% of open cases (p = 0.419). Within the NPH subgroup, the laparoscopically treated patients had significantly more overdrainage (p = 0.040), whereas those in the open cohort experienced significantly more shunt obstructions (p = 0.034). Laparoscopically treated patients had shorter operative times (p < 0.0005), inpatient LOS (p < 0.001), and inpatient LOS after VP shunt placement (p = 0.01) as well as less blood loss (p = 0.058).
Conclusions
To our knowledge this is the largest reported comparison of distal VP shunt catheter insertion techniques. Compared with minilaparotomy, the laparoscopic approach was associated with decreased time in the operating room and a decreased LOS. Moreover, laparoscopy was associated with fewer distal shunt obstructions. Laparoscopic shunt surgery is a viable alternative to traditional shunt surgery.
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Affiliation(s)
| | - Joshua L. Argo
- 2General Surgery, Department of Surgery, University of Alabama
| | | | | | - R. Shane Tubbs
- 3Section of Pediatric Neurosurgery, Children's Hospital, Birmingham, Alabama; and
| | - Ronald H. Clements
- 4Division of General Surgery, Department of Surgery, Vanderbilt University, Nashville, Tennessee
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Reddy GK, Shi R, Guthikonda B. Obstructive Hydrocephalus in Adult Patients: The Louisiana State University Health Sciences Center—Shreveport Experience with Ventriculoperitoneal Shunts. World Neurosurg 2011; 76:176-82. [DOI: 10.1016/j.wneu.2011.01.032] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2010] [Revised: 10/22/2010] [Accepted: 01/22/2011] [Indexed: 11/27/2022]
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Bigger is bigger. Better is better. Acta Neurochir (Wien) 2011; 153:1237-43; author reply 1245. [PMID: 21541685 PMCID: PMC3098966 DOI: 10.1007/s00701-011-1030-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2011] [Accepted: 04/08/2011] [Indexed: 11/30/2022]
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Korinek AM, Fulla-Oller L, Boch AL, Golmard JL, Hadiji B, Puybasset L. Morbidity of Ventricular Cerebrospinal Fluid Shunt Surgery in Adults: An 8-Year Study. Neurosurgery 2011; 68:985-94; discussion 994-5. [PMID: 21221037 DOI: 10.1227/neu.0b013e318208f360] [Citation(s) in RCA: 80] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Abstract
BACKGROUND:
Cerebrospinal fluid (CSF) shunt procedures have dramatically reduced the morbidity and mortality rates associated with hydrocephalus. However, despite improvements in materials, devices, and surgical techniques, shunt failure and complications remain common and may require multiple surgical procedures.
OBJECTIVE:
To evaluate CSF shunt complication incidence and factors that may be associated with increased shunt dysfunction and infection rates in adults.
METHODS:
From January 1999 to December 2006, we conducted a prospective surveillance program for all neurosurgical procedures including reoperations and infections. Patients undergoing CSF shunt placement were retrospectively identified among patients labeled in the database as having a shunt as a primary or secondary intervention. Revisions of shunts implanted in another hospital or before the study period were excluded, as well as lumbo- or cyst-peritoneal shunts. Shunt complications were classified as mechanical dysfunction or infection. Follow-up was at least 2 years. Potential risk factors were evaluated using log-rank tests and stepwise Cox regression models.
RESULTS:
During the 8-year surveillance period, a total of 14 275 patients underwent neurosurgical procedures, including 839 who underwent shunt placement. One hundred nineteen patients were excluded, leaving 720 study patients. Mechanical dysfunction occurred in 124 patients (17.2%) and shunt infection in 44 patients (6.1%). These 168 patients required 375 reoperations. Risk factors for mechanical dysfunction were atrial shunt, greater number of previous external ventriculostomies, and male sex; risk factors for shunt infection were previous CSF leak, previous revisions for dysfunction, surgical incision after 10 am, and longer operating time.
CONCLUSION:
Shunt surgery still carries a high morbidity rate, with a mean of 2.2 reoperations per patient in 23.3% of patients. Our risk-factor data suggest methods for decreasing shunt-related morbidity, including peritoneal routing whenever possible and special attention to preventing CSF leaks after craniotomy or external ventriculostomy.
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Affiliation(s)
| | | | | | - Jean-Louis Golmard
- Biostatistical Unit, Pitié-Salpêtrière Hospital, Assistance Publique–Hôpitaux de Paris and Pierre and Marie Curie University, Paris, France
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Reddy GK, Bollam P, Caldito G, Willis B, Guthikonda B, Nanda A. Ventriculoperitoneal shunt complications in hydrocephalus patients with intracranial tumors: an analysis of relevant risk factors. J Neurooncol 2010; 103:333-42. [DOI: 10.1007/s11060-010-0393-4] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2010] [Accepted: 08/27/2010] [Indexed: 10/19/2022]
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Zunt JR. Infections of the central nervous system in the neurosurgical patient. HANDBOOK OF CLINICAL NEUROLOGY 2010; 96:125-141. [PMID: 20109679 DOI: 10.1016/s0072-9752(09)96009-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Affiliation(s)
- Joseph R Zunt
- Department of Neurology, Harborview Medical Center, Seattle, WA 98104, USA.
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Ishikawa M, Hashimoto M, Kuwana N, Mori E, Miyake H, Wachi A, Takeuchi T, Kazui H, Koyama H. Guidelines for management of idiopathic normal pressure hydrocephalus. Neurol Med Chir (Tokyo) 2008; 48 Suppl:S1-23. [PMID: 18408356 DOI: 10.2176/nmc.48.s1] [Citation(s) in RCA: 146] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
With the rapid aging of Japanese society, medical care of the elderly has become an important social issue. Among various disorders manifesting dementia, gait disturbance, and urinary incontinence in the elderly population, normal pressure hydrocephalus (NPH), especially of idiopathic type (iNPH), is becoming noteworthy. The Guidelines for management of iNPH in Japan are created in compliance with the evidence-based medicine methods and published in 2004. This English version is made to show the diagnosis and treatment of iNPH with reference to the socio-medical background in Japan and to promote the international research on iNPH. They propose three diagnostic levels; possible, probable, and definite. They indicate the diagnostic importance of high convexity tightness and dilated sylvian fissure with mild to moderate ventriculomegaly on coronal magnetic resonance imaging. The cerebrospinal fluid tap test is regarded as an important diagnostic test because of its simplicity to perform and high predictability of the shunt efficacy. The use of programmable valves at shunt surgeries is recommended. Flowcharts for diagnosis, preoperative assessment, and prevention for complications of shunt surgery are made to promote a wide use of them.
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Hoh BL, Lang SS, Ortiz MV, Chi YY, Lewis SB, Pincus DW. LOWER INCIDENCE OF REOPERATION WITH LONGER SHUNT SURVIVAL WITH ADULT VENTRICULOPERITONEAL SHUNTS PLACED FOR HEMORRHAGE-RELATED HYDROCEPHALUS. Neurosurgery 2008. [DOI: 10.1227/01.neu.0000319527.34738.9d] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Hoh BL, Lang SS, Ortiz MV, Chi YY, Lewis SB, Pincus DW. LOWER INCIDENCE OF REOPERATION WITH LONGER SHUNT SURVIVAL WITH ADULT VENTRICULOPERITONEAL SHUNTS PLACED FOR HEMORRHAGE-RELATED HYDROCEPHALUS. Neurosurgery 2008; 63:70-4; discussion 74-5. [DOI: 10.1227/01.neu.0000335072.32105.38] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
ABSTRACT
OBJECTIVE
The incidence of reoperation for ventriculoperitoneal shunts (VPS) in adults, although lower than in pediatric patients, is not insignificant. We hypothesize that adult VPS placed for hemorrhage-related hydrocephalus have a lower incidence of reoperation than those placed for other types of hydrocephalus.
METHODS
We retrospectively reviewed all adult (≥ 20 yr) VPS initially placed from February 2001 to August 2006 at the University of Florida. We determined the incidence and time interval to reoperation. Follow-up was conducted by telephone interview and review of medical records.
RESULTS
A total of 286 adult VPS were initially placed: 96 (34%) hemorrhage and 190 (66%) nonhemorrhage. A total of 15 (16%) hemorrhage patients underwent 22 shunt reoperations, compared with 50 (27%) nonhemorrhage patients who underwent 82 shunt reoperations (P = 0.0316). A Poisson regression analysis of the number of reoperations, factoring hemorrhage, age, and sex, demonstrated a significantly lower incidence of reoperation in hemorrhage patients (P = 0.0900). A Cox proportional hazards model analysis of time to first reoperation, factoring hemorrhage, age, and sex, demonstrated a significantly longer shunt survival in hemorrhage patients (P = 0.0404).
CONCLUSION
Adult VPS placed for hemorrhage-related hydrocephalus have a significantly lower incidence of reoperation and significantly longer shunt survival. This result may be related to an incidence of transient shunt dependency in patients with hemorrhage-related hydrocephalus. However, the precise mechanism remains unclear.
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Affiliation(s)
- Brian L. Hoh
- Department of Neurological Surgery, University of Florida College of Medicine, Gainesville, Florida
| | - Shih-Shan Lang
- Department of Neurological Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | | | - Yueh-Yun Chi
- University of Florida College of Medicine, Gainesville, Florida
| | - Stephen B. Lewis
- Department of Neurological Surgery, University of Florida College of Medicine, Gainesville, Florida
| | - David W. Pincus
- Department of Neurological Surgery, University of Florida College of Medicine, Gainesville, Florida
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Lee SC, Chen JF, Tu PH, Lee ST. Cerebrospinal fluid galactorrhea: a rare complication of ventriculoperitoneal shunting. J Clin Neurosci 2008; 15:698-700. [PMID: 18378141 DOI: 10.1016/j.jocn.2007.04.018] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2006] [Revised: 04/17/2007] [Accepted: 04/26/2007] [Indexed: 10/22/2022]
Abstract
In this report we describe a 26-year-old woman who had an intra-abdominal pseudocyst located at the peritoneal catheter tip following ventriculo-peritoneal (VP) shunt implantation. Retrograde cerebrospinal fluid (CSF) flowed outside the catheter and communicated with the right breast lactiferous ductal system and leaked from the nipple orifice. CSF galactorrhea only occurs when the lactiferous duct is injured during VP shunt implantation, in combination with the formation of an intra-abdominal CSF pseudocyst prior to lactiferous duct healing. Leakage of CSF from the nipple orifice can be successfully treated by simply guiding the peritoneal catheter tip into the peritoneal cavity through a new laparotomy; that is, shunt revision is not always required.
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Affiliation(s)
- Sai-Cheung Lee
- Department of Neurosurgery, Chang Gung University and Chang Gung Memorial Hospital, Kweishan, Taoyuan, Taiwan
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Abstract
OBJECT The goal of this study was to determine whether failure rates of hydrocephalus shunts have fallen over the years as a result of experience or technical improvements. METHODS A structured search was performed of the English language literature for case series reporting failure rates after shunt insertion. A metaanalytic model was constructed to pool data from multiple studies and to analyze failure rates statistically for temporal trends. Separate models were used for children (< 17 years old) and adults. RESULTS In children, the shunt failure rate was 31.3% for the 1st year and 4.5% per year thereafter. There were no significant changes in either rate over time. Although 1st-year failure rates in adults have fallen slightly over time, late failure rates have risen. CONCLUSIONS Progress in preventing shunt failures has not been made over the last several decades. Any improvements made in shunt materials or insertion techniques have been overshadowed by biological and other factors.
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Affiliation(s)
- Sherman C Stein
- Department of Neurosurgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania 19106, USA.
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Alcázar L, Alfaro R, Tamarit M, Gómez-Angulo JC, Ortega JM, Aragonés P, Jerez P, Salazar F, del Pozo JM. Delayed intracerebral hemorrhage after ventriculoperitoneal shunt insertion. Case report and literature review. Neurocirugia (Astur) 2007; 18:128-33. [PMID: 17497059 DOI: 10.1016/s1130-1473(07)70299-3] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
We present another case of delayed intracerebral hemorrhage after a ventriculoperitoneal (VP) shunting procedure. In this case, a right occipital intraparenchymal hematoma and associated intraventricular hemorrhage occurred six days after the operation for hydrocephalus secondary to subarachnoid hemorrhage in a 64 year old woman. It is a rare complication of VP shunting, with few cases reported previously in the literature. The presumed mechanism is the erosion of a cerebral blood vessel secondary to a close contact with the ventricular catheter; bleeding disorder, vascular malformation, head trauma or brain tumor were excluded in this patient.
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Affiliation(s)
- L Alcázar
- Department of Neurosurgery, The Getafe Universitary Hospital, Getafe.,Madrid, Spain
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Shahul Hameed AS, Yousaf I, Choudhari KA. Urinary bladder calculi complicating ventriculo-vesical shunt. Br J Neurosurg 2006; 19:449-50. [PMID: 16455572 DOI: 10.1080/02688690500390458] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
A rare case of vesical calculi complicating the procedure of ventriculo-vesical shunt is presented. In addition to highlighting technical difficulties in placing shunt catheters into the urinary system, the potential complications are discussed. We consider this route of cerebrospinal fluid(CSF) diversion less physiological compared with the peritoneal, pleural or the venous sites, and discourage use of the urinary bladder as the drainage site for the shunting of CSF.
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Affiliation(s)
- A S Shahul Hameed
- Department of Neurosurgery, Regional Neuroscience Unit, Royal Victoria Hospital, Belfast, UK
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Enger PØ, Svendsen F, Sommerfelt K, Wester K. Shunt revisions in children--can they be avoided? Experiences from a population-based study. Pediatr Neurosurg 2005; 41:300-4. [PMID: 16293949 DOI: 10.1159/000088732] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2005] [Accepted: 05/04/2005] [Indexed: 11/19/2022]
Abstract
BACKGROUND Shunt failure is by far the most frequent problem in children with shunts, and most of them will experience this condition at some point in their lives. In order to identify causes of shunt failure, and to compare multi-component and one-piece shunt systems, we analyzed retrospectively all pediatric shunt procedures in our Department during an 11-year period. The study does not deal with shunt infections. METHODS We reviewed the records of all pediatric shunting procedures between January 1986 and December 1996. RESULTS The study included 161 children operated for hydrocephalus with a total of 431 procedures. The procedures included 124 (29%) primary insertions, 10 (2%) reinsertions and 297 (69%) revisions; 206 (69%) of the revisions were due to shunt failures, of which 74 (36%) were caused by the failure of the surgical technique (misplaced ventricular catheters, disconnected shunts, or misplaced peritoneal catheters). CONCLUSIONS Improvement of the surgical technique may reduce the incidence of shunt failures and revisions. The results obtained in a small department like ours do not seem to differ substantially from those obtained in more specialized departments with a larger patient group. Practical measures that may reduce the risk of shunt failures are suggested.
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Affiliation(s)
- Per Ø Enger
- Department of Neurosurgery, Haukeland University Hospital, Bergen, Norway
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49
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Abstract
In 10% of adult patients with hydrocephalus, the cause is because of aqueductal stenosis (AS), causing enlargement of the lateral and third ventricles. There are currently two alternate forms of surgical treatment for AS; shunt surgery and ventriculostomy. Shunt surgery is associated with high complication rates and many patients need revisions, but the effectiveness is high. Endoscopic third ventriculostomy (ETV), re-establishing a physiological route of CSF dynamics, has become the treatment of choice for AS in most neurosurgical centers. ETV has fewer complications and revisions are rare, but some patients need shunt surgery to improve despite a patent ventriculostomy. There are today no common criteria for patient selection to either ETV or ventriculo-peritoneal shunt surgery.
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Affiliation(s)
- M Tisell
- Institute of Clinical Neuroscience, Sahlgrenska University Hospital, Göteborg University, Sweden.
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50
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Arriada N, Sotelo J. Continuous-flow shunt for treatment of hydrocephalus due to lesions of the posterior fossa. J Neurosurg 2004; 101:762-6. [PMID: 15540913 DOI: 10.3171/jns.2004.101.5.0762] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Management of hydrocephalus caused by expansive lesions of the posterior fossa is complicated by two main drawbacks of shunt devices: sudden decompression and overdrainage. The ventriculoperitoneal (VP) continuous-flow (CF) shunt is characterized by a peritoneal catheter with an internal diameter of 0.51 mm that promotes continuous drainage of cerebrospinal fluid (CSF) at its production rate. The authors have previously demonstrated in adult patients with hydrocephalus that sudden decompression and overdrainage are absent when this shunt is used; here they report the findings of a prospective study in which the goal was to test the performance of this shunt in patients with severe hydrocephalus due to lesions of the posterior fossa. METHODS During a 5-year period, 103 patients with severe hydrocephalus caused by lesions of the posterior fossa were treated by placement of a VP shunt. In 53 of these patients (control group) a shunt and valve system was surgically implanted and in 50 patients a CF shunt was implanted. All patients were followed up for a minimum of 2 years after surgery. Shunt revision or change was necessary in 21 patients (40%) with conventional shunts and in four patients (8%) with the CF shunt (p < 0.003). Signs of overdrainage were observed in 18 patients (34%) in the control group, four of whom had ascending transtentorial herniation; this complication was not seen in patients with the CF shunt. CONCLUSIONS The CF shunt had a low rate of dysfunction and an absence of complications caused by overdrainage, which were frequently associated with the control shunts. The hydrodynamic properties of the CF shunt make it effective, even in severe cases of hydrocephalus caused by lesions of the posterior fossa.
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Affiliation(s)
- Nicasio Arriada
- Research and Neurosurgical Divisions, National Institute of Neurology and Neurosurgery of Mexico, Mexico City, Mexico
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